Pulmonary Artery Injury Following Endocardial Left Atrial Appendage Occlusion: The Known and Unknown.

Background: Left atrial appendage closure (LAAC) is frequent alternative for stroke prophylaxis in patients for whom oral anticoagulation is contraindicated. Pulmonary artery injury (PAI) is a feared yet rare complication of endocardial LAAC, but its surrounding literature is scarce.

Objectives: The aim of the current study was to review prior PAI published reports and the U.S. Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database to understand evidence and mechanisms of PAI after LAAC.

Methods: A systematic review was conducted of the literature and MAUDE database for previously reported cases of PAI, and cases were reviewed for patient characteristics and outcomes. In addition, we identify risks and review our strategies to avoid this injury.

Results: Thirty-six cases (16 case reports and 20 MAUDE reports) of PAI were found. These patients had a mean age of 73.6 ± 8.2 years with a median CHA₂DS₂VASC score of 5 (quartile 1-quartile 3: 3-6). Most commonly, LAAC associated with PAI involved a dual-seal (75%) followed by lobular occlusive devices (19.4%); the device was unspecified in 2.8% of cases. PAI commonly presented postprocedurally, either within the first 24 hours (50%) or beyond (38.9%), with cardiac tamponade (61.1%) or cardiac arrest (19.4%). Overall, 52.8% required surgery with or without antecedent pericardiocentesis, and 16.7% were managed with pericardiocentesis. PAI was associated with a high mortality rate (ie, 33.3%). Unfortunately, no specific cardiac imaging or procedural details to predict PAI were noted in the reports.

Conclusions: Presentation of PAI after LAAC can occur immediately following the procedure or be delayed. Thus, the threshold for suspicion, especially with rapid and hemodynamically significant pericardial effusion, after LAAC should be low.